Summer Camp Registration

Name of person filling out application

I am a UofL staff, faculty or student (Note: UofL ID must be presented first day of camp when dropping off your child)

Email Address

Are you already a Gheens Science Hall & Rauch Planetarium Member? (Please note that you must have an active membership at the time of the summer camp to be eligible for the member discount.) Yes No

Please let us know how you heard about our Summer Camps.

Sign up for a membership if you wish to become a member and receive discounts on workshops and camps as well as free admission to regular planetarium shows.

Camp/Session Choices

Child 1

Choose a camp session Space Adventure Camp, June 18-22, 9am-4pm, Grades 2-4 Art Stars Camp, June 25-29, 9am-4pm, Grades 1-3 Space Adventure Camp, July 16-20, 9am-4pm, Grades 2-4 Space Engineering Camp, July 23-27, 9am-4pm, Grades 5-6

Child Information

Parent/Guardian Information

Parent/Guardian 1 Information

First Name

Last Name

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Secondary Phone Number [###-###-####]

Street Address 1

Street Address 2 [optional]

City

State [All Caps]

Zip Code

Parent/Guardian 2 Information [optional]

First Name

Last Name

Primary Phone Number [###-###-####]

Secondary Phone Number [###-###-####]

Street Address 1

Street Address 2 [optional]

City

State [All Caps]

Zip Code

Additional Authorized Pick-Up Information [optional]

Contact/Pick-Up 1 Information

First Name

Last Name

Relationship

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Secondary Phone Number [###-###-####]

Contact/Pick-Up 2 Information

First Name

Last Name

Relationship

Primary Phone Number [###-###-####]

Secondary Phone Number [###-###-####]

Physician/Insurance Information

Name of Family Physician

Phone Number [###-###-####]

Insurance Carrier

Policy Number

Summer Camp Registration

Camp/Session Choices

Child Information

Medical Information

Medical Information

Parent/Guardian Information

Additional Authorized Pick-Up Information [optional]